Therapeutic Decision-Making for MS - Flowchart
Therapeutic Decision-Making for MS - Flowchart
«Flowchart»

Start

Start

Start

A

DECISION-MAKING ALGORITHM FOR RELAPSING-REMITTING MS

A

A

DECISION-MAKING ALGORITHM FOR RELAPSING-REMITTING MS

DECISION-MAKING ALGORITHM FOR RELAPSING-REMITTING MS ECISION- AKING LGORITHM FOR ELAPSING- EMITTING A

B

DECISION-MAKING ALGORITHM FOR PROGRESSIVE MS

B

B

DECISION-MAKING ALGORITHM FOR PROGRESSIVE MS

DECISION-MAKING ALGORITHM FOR PROGRESSIVE MS ECISION- AKING LGORITHM FOR ROGRESSIVE B

Relapsing-Remitting MS

Relapsing-Remitting MS

Relapsing-Remitting MS

Relapsing-Remitting MS

Acute neurologic change

Acute neurologic change

Acute neurologic change

Stable

Stable

Stable

Symptomatic therapy

Symptomatic therapy

Symptomatic therapy

Progressive MS

Progressive MS

Progressive MS

Progressive MS

Secondary progressive MS

Secondary progressive MS

Secondary progressive MS

Primary progressive MS

Primary progressive MS

Primary progressive MS

End

End

End

No proven treatment

No proven treatment

No proven treatment


    IFN-ß1a, or
    IFN-ß1b

    IFN-ß1a, or
    IFN-ß1b

    IFN-ß1a, or
    IFN-ß1b

IFN-ß1a, or or
IFN-ß1b

With relapses

With relapses

With relapses

Without relapses

Without relapses

Without relapses

Intolerant or poor response

Intolerant or poor response

Intolerant or poor response

Consider treatment with one of the following:


    Mitoxantrone
    Azathioprine
    Methotrexate
    Pulse cyclophosphamide
    IVIg
    Pulse methylprednisolone

Consider treatment with one of the following:


    Mitoxantrone
    Azathioprine
    Methotrexate
    Pulse cyclophosphamide
    IVIg
    Pulse methylprednisolone

Consider treatment with one of the following:


    Mitoxantrone
    Azathioprine
    Methotrexate
    Pulse cyclophosphamide
    IVIg
    Pulse methylprednisolone

Mitoxantrone
Azathioprine
Methotrexate
Pulse cyclophosphamide
IVIg
Pulse methylprednisolone

Consider

Consider

Consider

Identify and treat any underlying infection or trauma

Identify and treat any underlying infection or trauma

Identify and treat any underlying infection or trauma

Exacerbation

Exacerbation

Exacerbation

Pseudoexacerbation

Pseudoexacerbation

Pseudoexacerbation

Symptomatic therapy

Symptomatic therapy

Symptomatic therapy

Methylprednisolone/prednisone

Methylprednisolone/prednisone

Methylprednisolone/prednisone

Functional impairment

Functional impairment

Functional impairment

No functional impairment

No functional impairment

No functional impairment


Low attack frequency or single attack
Normal neurologic examination
Low disease burden by MRI


Low attack frequency or single attack
Normal neurologic examination
Low disease burden by MRI


Low attack frequency or single attack
Normal neurologic examination
Low disease burden by MRI


Low attack frequency or single attack
Normal neurologic examination
Low disease burden by MRI

Yes

Yes

Yes

No

No

No

Options:


    Oral (DMF, fingolimod, or (teriflunomide)
    Natalizumab (if JCV-negative)

Options:


    Oral (DMF, fingolimod, or (teriflunomide)
    Natalizumab (if JCV-negative)

Options:


    Oral (DMF, fingolimod, or (teriflunomide)
    Natalizumab (if JCV-negative)

Oral (DMF, fingolimod, or (teriflunomide)
Natalizumab (if JCV-negative)

Initial course

Initial course

Initial course

Mild

Mild

Mild

Moderate or severe

Moderate or severe

Moderate or severe

Continue therapy

Continue therapy

Continue therapy

Options:


    Injectable (GA or IFB-ß)
    Oral (DMF, fingolimod, or (teriflunomide)
    Natalizumab (if JCV-negative)

Options:


    Injectable (GA or IFB-ß)
    Oral (DMF, fingolimod, or (teriflunomide)
    Natalizumab (if JCV-negative)

Options:


    Injectable (GA or IFB-ß)
    Oral (DMF, fingolimod, or (teriflunomide)
    Natalizumab (if JCV-negative)

Injectable (GA or IFB-ß)
Oral (DMF, fingolimod, or (teriflunomide)
Natalizumab (if JCV-negative)

Good response

Good response

Good response

Intolerant or poor response

Intolerant or poor response

Intolerant or poor response

Good response

Good response

Good response

Successive trials of alternatives*

Successive trials of alternatives*

Successive trials of alternatives*

* *

* Can include trials of different preparations of interferon ß (IFN-ß) particularly advancing from once-weekly (Avonex) to a more frequent (e.g., Rebif, Betaseron/Extavia) dosing regimen. Options also include use of natalizumab in JC virus-positive pts.

* Can include trials of different preparations of interferon ß (IFN-ß) particularly advancing from once-weekly (Avonex) to a more frequent (e.g., Rebif, Betaseron/Extavia) dosing regimen. Options also include use of natalizumab in JC virus-positive pts.

* Can include trials of different preparations of interferon ß (IFN-ß) particularly advancing from once-weekly (Avonex) to a more frequent (e.g., Rebif, Betaseron/Extavia) dosing regimen. Options also include use of natalizumab in JC virus-positive pts.

*

Options:


    Oral (DMF, fingolimod, or (teriflunomide)
    Natalizumab (if JCV-negative)

Options:


    Oral (DMF, fingolimod, or (teriflunomide)
    Natalizumab (if JCV-negative)

Options:


    Oral (DMF, fingolimod, or (teriflunomide)
    Natalizumab (if JCV-negative)

Oral (DMF, fingolimod, or (teriflunomide)
Natalizumab (if JCV-negative)

Continue periodic clinical/MRI assessments

Continue periodic clinical/MRI assessments

Continue periodic clinical/MRI assessments

Repeat clinical examination and MRI in 6 months

Repeat clinical examination and MRI in 6 months

Repeat clinical examination and MRI in 6 months

Clinical or MRI change

Clinical or MRI change

Clinical or MRI change

No change

No change

No change